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Tuesday, August 30, 2016

The last three days we’ve been at another historic mission
hospital on the eastern slopes of Mt. Kenya, founded over a century ago by
Scottish Presbyterians.Chogoria is the
site of our newest Serge Kenya team.We
were asked to recruit doctors there to support the Kabarek University Family
Medicine Residency Program.Relatively
few doctors in Kenya have the opportunity to go on for a “master’s” degree
(residency) after their internship.Yet
these young men and women, after a 5-year post-high-school combined
university/medical degree program and a 1-year internship are expected to
manage all-comers at hospitals, from an ectopic pregnancy surgery to outpatient
diabetes care to critically ill newborns to a hernia repair.It’s a lot to expect, so the Family Medicine
residency here (unlike the USA which is more outpatient and primary-care
oriented) gives the trainees four more years of mentored experience and
intensive discipleship to prepare them with the skills and character to lead in
managing a district-level health team as hospitalists and administrators.

In Chogoria we collaborate with the Presbyterian Church of
East Africa which has hired some solid Kenyan consultants in Family Medicine,
Surgery, and OB, and the World Gospel Mission who sent an Emergency-Medicine
trained former-military couple to lead the team (currently on a year’s
sabbatical).Our Serge contribution
consists of three more families:Jason B
(med-peds) and Ree’l (business and admin); Derek W (PA) and Lauren (nurse); and
soon-to-arrive Larry S (family med) and Beth (lawyer transitioning to advocacy
work within the church).Our team teaches
not only the residents but a couple dozen clinical officer (PA) and medical
officer (doctor) interns, plus two recently-graduated doctors.They provide patient care, supervise rounds,
prepare lectures, ponder protocols, trouble-shoot equipment, help with
budgeting and quality improvement, reach out to the community in Bible clubs,
and generally model what it means to be a follower of Jesus in the context of
the needs in a small town in rural Kenya.

This work grew out of the trip Scott, Jack, and I made to
Chogoria a year and a half ago, with our team on the ground now for less than a
year.So a visit this weekend was an
opportunity to witness the early stages of collaboration and to encourage our
young team members.Thanks to Karen M
they spent their first few months in the same Swahili program we are currently
using, enabling them to bond with the culture and place and lay a foundation
for relationship.Some of the very
deteriorated housing has been rehabilitated to the level of livable.Now they are into that sticky phase of
plunging into all the beauty and dysfunction of a rural hospital in a poor
place.

The highlight of the time was definitely just connecting
with the families. If being a team
leader is a bit parental (in the healthy sense of leading, setting direction,
fostering the gifts of those we led, lots of meals and late night talks and
trips and fun, daily presence, being responsible/blamed, etc.), being an Area
Director affords the taste of the grandparental life stage. We show up intermittently bearing a few
gifts, marvel over cuteness and growth, get hosted and served meals, listen and
pray and offer perspective and praise, then try to direct some resources where
needed. It’s actually pretty fun.

Church, a picnic by the shared neighborhood rope swing, an
afternoon prayer time for God’s work in this place, dinners and evenings with
each family, hikes into the forested ravines, and then hospital rounds and
meetings.It was a “Choglorious” weekend
(Lauren taught us that adjective).And
by Choglorious, we don’t mean perfect.There are bumps galore.Interns
who so want to be helpful and positive that they may think or wish they
checked a lab or did a history when in actuality they are making it up.Antibiotics that aren’t given, machines that
are broken, labs that are unreliable.People whose plans change, who leave or never show up.Salaries that aren’t paid.Theology that veers dangerously towards the
“health and wealth” heresy.Yes, this
team has some serious work ahead. It's a climb steeper than the actual physical rock scramble (note all the kids on backs) we did Sunday afternoon.

So what does “Choglorious” mean?I think it takes the word “glorious” and
gives it a Swahili relative prefix, “cho”.Meaning, glory in the relative position of the here and now.Glory that God is working in the dust of
Kenya.The glory of preemie twins
basking in the warmth of an NICU that looks almost more biblically
stable-ish.The glory of a worshipful
voice in spite of a static-laden microphone.The glory of thriving children whose friend and activity horizons are
rather limited.The glory of a
17-year-old AIDS patient who landed in a bed where a caring and competent
med-peds doctor will think through his care and give him the best shot at
survival.The glory of collaboration,
imperfection, tiny steps towards quality improvement.The glory of the word made flesh, right here
in Chogoria.

Saturday, August 27, 2016

Clearly the last few weeks of intensive Swahili and repeated transition and goodbye have taken a toll, and blog writing has lagged for me. If you're on our prayer e-mail list you should have heard from us a couple of times in August (email me if you wanted to but did not). Last week Luke was on break from his 3rd year of UVA Medical School and took time to write his family and some friends a thoughtful, reflective email about his experience thus far. With his permission, here are his thoughts. He can use your prayers as well, so read and remember him.

The date is August 18th, I'm at a suburban poolside outside of Boston visiting my roommate's family, a 90's summer playlist is booming and we have officially completed the first half of our third year at UVA medical school. This is our week to sleep in, spend time outside, and let the minutes trickle by without panicking about tomorrow's responsibilities.

We are only a fraction, a sliver, of our way through medical training. Already thoughts of specialty choices, residency programs, MPHs, and research opportunities, loom. For all practical purposes we are the bottom of the food chain. We hold the retractors, we fax requests for medical records, we call family practices to set up appointments, we wait our turn to listen to the pneumatic lung or a mitral murmur.

In the last year, however, a crucial line was crossed. With the advent of our first board exam, pure theory was exchanged for the gritty mess of the wards. Flashcards were replaced with scrawled patient notes. We began scrolling through the EPIC medical record system instead of question banks. Late nights at the library fell way to shifts scuttling around the Emergency Department. The shift from wide eyed trepidation to undeserved confident swagger is already underway.

It is hard to avoid the cliches, to bring a fresh perspective to a profession packed with sharp and insightful minds... but wisdom from the mouth of babes, right?

Two experiences stand out, as book ends.

The first, in my first month, the beginning of a life. My first day on the labor and delivery service on the eighth floor I scrubbed in to my first cesarean section. One of the most common surgical operations worldwide, it is a dramatic decision, a rescue mission. Armed with forceps, clamps, scalpels, and scissors, we slice and tear through each layer of the abdomen (carefully delineated in every medical student's mind: skin, superficial fascia, deep fascia, anterior rectus sheath, rectus abdominus muscle, transversalis fascia, extraperitoneal connective tissue, peritoneum, uterine wall ). There is no subtlety, little delicate detail. Surgeons make a small incision in the muscular vascularized wall of the uterus, insert two fingers, and literally tear it open. I was engrossed in the anatomy, the blood, the different tools and techniques. The amniotic sac burst in a literal flood of fluid, latex hands plunged in to the muck struggling to get a hold. Out of this chaotic mess emerged perfection. It's ironic, in retrospect, to be so unprepared for a moment that I knew was coming for hours. I shouldn't have been so taken aback. So overwhelmed. But I was.

My left hand supported the baby's neck while I dried him off, wiping some of the vernix caseosa from his eyes. I was thankful for the surgical mask, because the thing is, I couldn't stop smiling. I think I would have laughed out loud, from relief and joy and sheer wonder, if it wasn't for the stern surroundings.

From many waters came a mind and body that fit in the palm of my gloved purple hand.

The second, in my six month, a life already ended. I was on call for internal medicine with our team: student, intern, and resident. We were given the responsibility of admitting new patients, and manning the code pager (auspiciously lined with red warning tape). When the pagers went off, I wasn't even sure I was supposed to follow- they were normally just drills and medical student's usually aren't in the inner circle know-how. The room was a logistical and moral mess. Nurses and techs fumbled at both arms to put better lines in the patients vessels, one doctor had started CPR, my resident stood at the foot of the bed shouting instructions. You could taste blood and feces in the air. I primed bags of blood by pumping the cuff (inflating a bladder that would force the blood through the tubing into her system at a much higher rate than gravity would normally allow) while they gave multiple pushes of epinephrine and slapped AED stickers onto her chest. She was too big for most nurses to get any leverage with the chest compressions, so I stepped up to help, rehearsing the rate, depth, and placement, desperately acting like I had done this before. Each compression made a ripple spread out from her sternum, the sheer volume of fat between my palms and her heart absorbing the majority of the force I pressed down with. After my two cycles, an eternal four minutes, and 400 compressions, I called out a thready pulse in her left radial artery. Her eyes rolled back in her head in pure terror. Her heart started to beat again, but after we handed her off to the intensive care unit team, she died. My own heart hurt.

Both, moments of emotion and blood, flirting with the fine line between life and death. The first, an example to emulate. A decision to act, to intervene, to yank an infant out of it's suffocating prison of muscle and fluid, as it's heart dropped to dangerously slow rates. A nonpareil glimpse into the potential of every soul. The second, a lesson that still weighs on me. A futile shot at an impossible chance, a failure to foresee a very real possibility (I later learnt her heart stopped because of massive blood loss into her bowels- she was known to be in awful health and unstable, and was only 'full code' because her family had not accepted the harsh realities of her current state). We filled her last moments with pain, we smashed ribs and bathed her brain in adrenaline to keep her tissues oxygenated for a few extra minutes. I don’t think we are very good at knowing when less is more.

This time, for me, is not necessarily about making a difference. I am often a wallflower. It is about learning. We learn medical technicalities- drilling drugs and differentials in every free moment… But I’m also feeling out the edges of my own personality, charting the spheres that augur 80 hour work weeks.

I've learned that I don't shy away from a challenge. Even wallflowers need to speak up if they want to get their hands dirty in the muddle that is health care. Sometimes you wish your means justified the ends. I've learned that I truly enjoy the mystery medicine, the complex web of physiology and morals. I've learned that one of the few things I fear most is mediocrity, that I'll strive for my utmost wherever I end up.

I'm frequently asked what specialty I plan to pursue: what kind of doctor do I want to be? The only answer I have now, is a doctor who is committed and faithful, one who seeks to liberate the oppressed, one who works so others may live, who sacrifices for those he loves.

Sunday, August 14, 2016

“This story. .
.“ we begin.Phase Two.We’ve moved on from the pre-school level of colors, numbers, nouns, and
very simple action sentences, and into the world of stories. The first week our
stories progressed from a few pictures to Kindergarten and 1rst-grade level
books.Our teacher puts a picture or a
page in front of us, and we go around the table saying sentences.Some are quite simple, the woman is wearing a red shirt . . . the bananas are on top of the
table.Some get a little more
interesting, the woman feels sad because
she knows her children will be hungry because the monkey stole the
bananas.We speak, we get corrected,
we record the teacher talking, we listen to the recording and ask questions, we
list new vocabulary words and record him again using each new word in
sentences.We speculate on the way the
story will progress, then turn the page or pull out a new card and talk some more.

Stories give words and grammar meaning and power. We used to just work on sentence constructions, which have their merits, but connecting all our vocabulary and tenses into the context of a story makes much more sense. I'm reminded again of how we as humans are wired for story. We try to impose a narrative on what we see, and when we try to recall words or truth, we remember them in the setting of story. Certainly the Bible has some poetry and prophecy and propositional teaching, but the bulk of the pages reveal God through story.

As a person whose second story is about to be published, it is fitting that I'm immersed in these little Swahili stories, which can be so simple yet so rich. Praying that our story here in Kenya is that much more interesting because of the time we're spending now on monkeys and tables and doors left open.

Last night, Katie Ledecky won her 4th gold and 5th medal of this Olympics, setting a new world record in the 800 m freestyle. By 11.38 seconds. That's twenty times the margin of many races, or more. Here is her photo from the news:

After the heartbreaking defeat of the US women's football team, this was happy news indeed. But one has to wonder, how do you sift through the best swimmers all over the world and come up with an individual who is THAT MUCH better than her contemporaries, and 80 seconds faster than the comparable Olympic races of my childhood? How do human beings keep breaking records? Is there a limit to human speed and strength?

I don't know, but I am speculating that Ledecky's performance rests on a long historical foundation that enables athletes to push the margin just a bit further in each generation. A culture of valuing sports and achievements for women. Earlier and more consistent training, and pool access. Coaching techniques improve. Swimwear improves. Nutrition improves. Someone finesses the art of the turn. I don't know, but the proverbial wheel doesn't have to be reinvented from scratch for each generation, and that must help in some way, because the Olympics remind us that people keep achieving beyond our dreams.

The Lubwisi trip reminded us of that too. Rich and Alie B spent so many years on that orthography, which enabled the Tabbs and subsequently Charles and Hannington to translate the New Testament. We were there with D.H., who was doing village visits for community health for years before we arrived, so we could start new programs and significantly expand medical outreach. P.L. was there too, who had supervised clearing land and laying a foundation for our house before we arrived, so our house construction progressed to liveable in only 4 months, and we later had the energy for innovations like a flush toilet and improvised solar hot water. In probably any sector where we can think of our own work, we can acknowledge that we stood on broad shoulders of those who enabled us. People who came and lived in tents to negotiate the sites of initial housing, teams who invested in those buildings, who figured out how to import vehicles, who preached the Gospel and made friends. We didn't have to start from scratch, so we could go a little further. And so it goes for wave after wave of missionaries. Today's group might come to an established hospital or school, to houses that might need repair but are standing, to church denominations with 2nd or 3rd generation leaders, to accessible education and medicine and electricity and clean water. Which doesn't mean the work is any easier. What it means is that instead of laboring to collect rain water in a gutter, they can be consulting on a massive water purification system to serve tens of thousands. Instead of hours trimming the pesky kerosene fridge wick to slight coolness, they can plug in a humming electric unit and spend their energy on more important things. In the next decade, they will far surpass all that has gone before, and we will cheer.

So we celebrate Ms. Katie Ledecky, and her coaches, her team, her family, her relentless hard work, her discipline, her achievement. And as record after record falls, we celebrate not only the current tip-of-the-pyramid athlete but the historical mountain of people whose work brought them to this pinnacle. Our community stretches across cultures and through generations; our blessings flow from the sacrifices of others. And we pray that our little pushes in 2016, our small losses and sufferings, bear an eternal weight of glory for those that follow.

Thursday, August 04, 2016

For the last 24 hours, we’ve been at a family reunion. At least that is how quite a few of the
attendees described it, and since that was our hope we are thankful. As we left, I heard a doctor now serving in
Bundi say “this group is like a family and we need to get together every year!”

A few months ago when the Bible launching date was set, we
began to contact the various young people who have been a large part of our
life and try to organize a retreat for them.Our idea was to spend face-to-face time, offer some spiritual
encouragement and vision, and help them to build a sense of community and
connection with each other.This group
included the KuleLeadership Scholarship
recipients (and one Laura Case Trust funded) who were the sprouts that arose
from the buried seed of Dr. Jonah’s life:4 doctors, 1 MPH, and 1 clinical officer completed with 3 more doctors-in-training
in their final years of medical school and 1 beginning a degree in
nursing.Those who have graduated now
serve: one as the medical superintendent of Bundibugyo hospital, one who has
been fighting ebola in West Africa, one who is beginning internship, one who
was selected for an anesthesia residency/master’s program, and one who has
published a paper on immunisations. The group also included our foster-children
for want of a better word, those kids who grew up around us, were friends of
our own kids, spent their afternoons and weekends at our house, went on trips
with us, and for whom we took parental responsibility to pay their school
fees.A lab technician, an electrical
engineer, a library and information science university graduate, a diploma-holder
in agribusiness, a nearly-completed CPA accountant, a certificate-holder in
human resources, plus those still studying in a university business program and
teacher’s college.Plus the late Dr.
Jonah’s family, with one daughter having completed a degree in development and
another entering university for a degree in law.Plus a quorum of the former Bundibugyo
missionaries who have shared the privilege and challenge of all this parental
care with us.All in all we were about
40 people.

(Birungi Fred, a 5th year medical student from Christ School)

There was swimming in the chilly pool.There were happy hugs of remembrance.There were snaps galore, by the flowers, at
meals.There was solid teaching by Paul,
Dan, Scott and me.There were small
group prayer times, laying hands on these young people and bringing their needs
to God.There was feasting—the
guesthouse prepared outdoor tables with a BBQ of various meats including a
whole goat donated by Andrew the merchant in Fort Portal with whom we did so
much business over the years—and I was very happy to hear a comment “oh, this
is so much like Easter used to be at your house.”

But mostly there was praise to God.One young man reminded all of us that God
took us “from the dust”, we were not people who should be here, but only by His
grace have we come this far.We marveled
at the way this unlikely family came together.And we purposed to be instruments of God’s blessing going forward to
others.

(Scott and the most recent medical graduate, Dr. Katuramu Tadeo - also a Christ School grad)

Please pray for these young people.They are the future of Bundibugyo and
beyond.Most are orphans, and now with
their bit of education they are under pressure from their uncles and brothers
and sisters and cousins to solve unsolvable problems of debt, or sickness, or
addictions in those they love.Several
are married, so pray for their marriages, and for God’s leading to a
like-minded spouse for those that aren’t.About six have kids, so pray that their parenting would then be the
foundation of yet another generation of Kingdom committed people.Many asked for wisdom, all too aware that
even with their degrees they face more than they can handle in their work.Three still need jobs.And these young people will live by the way
of the cross, in ways familiar to some of us and ways beyond our
comprehension.One couple very dear to
us suffered 7 miscarriages before the birth of their sweet 2-month-old baby
girl.Another’s first-born son died
after a complicated birth, a year before they had their also sweet baby
girl.Another’s wife couldn’t come
because she is caring for their 1.4 kg premature baby.They face jealously, corruption, accidents,
loss, theft, failure, and discouragement.But for today they were triumphantly joyful in this community.

(all these went to CSB)

And let me close with a shout-out to schools, to our finance office, and to TCK’s.A large proportion of this group went to
Christ School Bundibugyo.They are the
fruit of the Bartkovich’s labor, the Pierces and the Isingomas and countless
other team members pulling along.It was
sweet to see these boys’ faces light up when they spotted their former
headmaster, Isingoma, at the table.In their
own words, they were not always the kids one hoped they would be, they caused
us some heartaches along the way, but it is encouraging to see them mature and
look back on those years at CSB as spiritually formative.We are grateful. And I hope that Dwight and Jerry see this post, and the faces behind all those requests and transfers and problems over the years. And I heard a theme over and over about our
kids, being their friends.In fact it is
the natural kid-to-kid friendship that my children offered a good proportion of
this group that probably had the biggest impact.When we look back on our Bundibugyo years, we
may find that the “non-ministry” hours spent with kids around and in our home,
all those meals and football games and catechism and stories, were the real
deal of bringing Jesus.

Our Mission

who we are

paradox:
1. something that combines contradictory features or qualities.
Life in Africa is full of contradictions - the beauty and pain; the abundance and the poverty; the joy and the sorrow.
Our lives, too...dying that we might live; strong in our weakness; sinners yet saints.
2. a "pair of docs"